A further recent development regards the new standards for psychosocial inter-vention in cancer. Unlike 30 years ago, when psychotherapy was not considered as scientific as other medical interven-tions, new data have provided evidence of the impact of psychological and psy-chosocial approaches in cancer (Fawzy et al, 1995). Psychological interventions, such as educational, coping and emotion-al support, and psychotherapy sensu stric-to have shown stric-to be of help in several studies. Fawzy (1999), discussing the rationale for psychosocial intervention in cancer care, points out that the diagnosis of cancer and consequent medical treat-ment determine psychological distress and emotional turmoil that can be specif-ically managed with psychosocial inter-vention. However, the choice of interven-tion is related to several variables, espe-cially the phase of illness. Thus, interven-tions will vary depending if the patient is in the diagnostic phase, in the initial treat-ment phase, in follow-up, or has had recurrence and re-treatment, or in the palliative phase. Demographic and clini-cal variables (eg, type of cancer, age, gen-der) should also be considered in decid-ing the best psychosocial intervention in
the context of cancer. The level of psy-chological distress is also important, since it has been shown that patients with the more intense symptoms seek psychoso-cial support compared with patients who have social support in their interpersonal lives (Plass and Koch, 2001). This under-scores the usefulness of proper psychoso-cial screening and evaluation guidelines as a way to refer patients in need of help to proper psycho-oncology services.
Group therapy has also been examined as an evidence-based intervention with a good cost-benefit ratio, in comparison with individual psychological therapy (Fawzy, 1998). However, more research is needed to address some unresolved prob-lems regarding the specific effects of psy-chotherapy in cancer patients. While the impact of psychosocial intervention in improving survival is not confirmed (Ross et al, 2002), the effects on well-being, anxiety and depression are clear (Sheard and Maguire, 1999). As recently suggested by Newell et al, (2002) the chal-lenge for the future is to improve the quality of studies on efficacy of psy-chotherapy in order to make more specif-ic the type of intervention for distinct psy-chological disorders or problems.
Conclusion
In conclusion, psycho-oncology has been a rapidly progressing subspecialty over the recent past. Results of research in psychological screening, education and psychosocial interventions strongly sup-port that view. The NCCN panel advises that further advancements in the immedi-ate future depend on: establishing
institu-PSYCHOPATHOLOGY
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tional multidisciplinary committees for implementation of standards and guide-lines; conducting multicenter trials that explore brief screening instruments and treatment guidelines; requiring
institu-tions to continuously monitor quality improvement in the psychosocial care of their patients as a priority; and developing educational approaches to distress man-agement for staff, patients, and families.
PSYCHIATRIC CONCOMITANTS OF CANCER
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Luigi Grassi, Professor of Psychiatry, University of Ferrara, Corso Giovecca 203, 44100 Ferrara, Italy E-mail: [email protected]
In a previous article we summarized the status of, and challenges in, the field of personality disorders (Tyrer and Simonsen, 2003). This subject continues to attract great interest at present and some recent developments illustrate this.
Classification
Areas of development: DSM and ICD under siege
The ICD-10 and DSM-IV personality disorder classifications have been in use since 1992 and 1994 respectively and are to be revised within the next 5 or 6 years, probably nearing the end of their useful life. Of the conditions within the group, schizotypal, borderline and anti-social (disanti-social) personality disorders continue to attract the most attention and seem likely to be maintained in some form in any revised classification.
Schizotypal personality disorder and schizotypy seems to be a mixture of trait and state features. It has a clear familial and neurobiological relationship to
schizophrenia spectrum disorders and should, according to the classification in ICD-10, belong to that group.
Emotionally unstable personality disor-ders (including borderline personality disorder) are a heterogeneous group with elements of mood disorder, identi-ty difficulidenti-ty, impulsiviidenti-ty, interpersonal problems and psychotic ideation within its ambit and it needs better definition.
Despite this, there is now considered to be sufficient evidence of treatment effectiveness to bring out practice guidelines (APA, 2001) and this has stimulated great interest. Antisocial and dissocial personality disorder remains a major public health problem and in some countries attempts are being made to bring it more under the responsibility of psychiatric services. This has been most marked in England and Wales, where a new diagnosis, “dangerous and severe personality disorder (DSPD)”
briefly emerged in 1999, only to be crit-icized with some force (Moran, 2002) and now replaced by the term “DSPD programme” with less emphasis on the diagnostic status of the condition.